Cohen's Brain Bits: How Much Rest Is Best After Concussion?

It's time to reconsider dogmatic principles in concussion management.

While rest in the first day or two following a concussion may help prevent further damage to the injured brain, prolonged rest may actually impede recovery in young patients, according to an exciting new study in the journal Pediatrics.

Standard practice of 24 to 48 hours of rest after concussion is based upon limited data, and many have advocated for extended periods of rest in a dark and quiet room, also known as "cocooning." But whether or to what extent this is actually helpful hasn't been supported by good-quality research.

The authors of the new study sought to settle the debate with a randomized, controlled trial studying 88 patients ages 11 to 22 who were diagnosed with concussion in a pediatric emergency room. Hypothesizing that stricter rest would reduce concussion symptoms and improve outcomes, they randomized 45 patients to 5 days of strict rest (intervention) while the other 43 were instructed to follow the standard 1-2 days rest followed by a step-wise return to activity (controls).

Much to the surprise of investigators, the intervention group fared worse than the controls, with patients reporting more daily postconcussive symptoms and a longer time to symptom resolution.

The trial's hypothesis was based upon a widely held assumption -- in neurology and elsewhere in medicine -- that rest paves a road to recovery. Yet, consider how the "intervention" might affect a young concussion patient.

Five days is a full week out of school, meaning that kids miss a considerable amount of class material, homework, school activities, sports, time with friends, family interactions, popular media, and much more. Stress and anxiety about missed work and catching up can interfere with healing. Depression can develop from lack of socializing or guilt from failure to participate in the big game or the school play. Lack of exercise can also lead to depression and insomnia.

There are certainly reasons to believe that a return to normal activities can promote recovery. Exercise has been shown to play a critical role in brain plasticity and healing in a variety of neurologic diseases. It reinstates normal cerebral blood flow by restoring balance to the cerebral autoregulation mechanism that is damaged in concussion and that leads to many concussive symptoms. One study even showed that patients randomized to either 6 days of complete bed rest versus patients with 4 days of very limited rest (only a few hours each day) had the same outcomes at 6 months, consistent with the findings in this study in Pediatrics.

Socialization has likewise been linked to improved function in neurologic disease and may play a role in neurogenesis and synaptogenesis. Interaction with friends and family may also provide emotional support that might aid the healing process and help prevent stress and psychological distress.

At the same time, previous concussion studies have demonstrated adverse consequences from sedentary isolation. Anxiety, stress, and depression have all been associated with a slower recovery from concussion, while social support and socialization are associated with improved outcomes. For all of these psychosocial factors, early intervention is extremely efficacious in reducing long-term symptomatology and is thus recommended by the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury.

This new study may thus give pause to concussion researchers, clinicians, and advocates who have urged extended post-concussion rest and suggest it is time to reconsider dogmatic principles in concussion management.

More study is certainly needed to establish evidenced-based protocols for intervention in the acute phase following concussion, but until such studies are complete, our approach in concussion should be informed by our current state of knowledge regarding best practice in the treatment of neurologic disease. As we better elucidate biomarkers for concussion and become more able to track healing using imaging studies, objective data will hopefully guide our investigation and recommendations, providing those with mild traumatic brain injury the best chance of speedy recovery.

Cohen's Brain Bits is a new feature at MedPage Today written by Joshua Cohen, MD, MPH, a neurologist at the Headache Institute and the Icahn School of Medicine at Mount Sinai in New York City.

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